Sea Spray Tan Client Intake Form

Name

First NameLast Name

Phone Number

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How Did You Hear About Us?

What Best Describes Your Skin Type?

very pale-always burns in the sunfair-tans lightly, burns easilymedium/olive-tans easily, sometimes burnsmoderate brown/olive-tans well, hardly burnsbrown/dark brown-tans dark, rarely burns

What Level of Tan Would You Like to Achieve?

lightnaturalbolddaring

Have you had a spray tan or used tanning products before?

YesNo

Have you shaved/waxed in the last 24 hours?

YesNo

Did you exfoliate in the past 24 hours?

YesNo

Have you had a sunburn within the past 3 months?

YesNo

Do you suffer with any respiratory problems?

YesNo

Are you pregnant or breastfeeding?

YesNo

Do you have any skin or pigmentation disorders?

YesNo

Is your skin hypersensitive?

YesNo

Have you known any allergies?

YesNo

Have you any open cuts/wounds/rashes?

YesNo

Have you recently had any body piercings or tattoos?

YesNo

Have you had any recent Botox or fillers?

YesNo

Are you currently taking accutane?

YesNo

Do You Use Any Retinols or Active Acids (AHAs) In Your Skin Care?

YesNo

Have you had any surgery or medical treatment in the last 3 months?

Do you give us permission to use photos of your tan for marketing purposes?

YesNo

Any questions?

Spray Tanning by use of DHA (active ingredient) is generally considered to be safe and has been FDA approved ONLY if you follow guidelines to protect mucous membranes. You may request measures to protect your eyes and mucous membranes and prevent inhalation. All ingredients used in this service are intended for cosmetic use and generally regarded as safe (ingredient list is available upon request). Individuals may be allergic to one or more ingredients in the spray tan solution. Spray Tanning does not provide protection from the sun and does not contain SPF.

Disclaimer: I declare that I have read and understood and answered the questions to the best of my knowledge. I have no known medical conditions or allergies that may affect or induce a harmful reaction from a sunless tanning treatment.

The information above is for the therapists records only and will not be misused or passed on to any other third-parties.

Signature

Date